Care Transition Associate- PAH

Company:

Providence at Home with Compassus

 

Position Summary

The Care Transition Associate performs a variety of patient-centered administrative tasks to support care coordination within acute care hospital hubs. This care transition work is focused on post-acute care needs for patients requiring home health and hospice . Support patients and families with their specific discharge plan and plan of care for home health and hospice referrals. The Care Transition Associate ensures a high level of customer service and connection between the hospital's patients and post-acute service providers by assisting patients and the clinicians who provide care to access appropriate post-acute care and effectuate a timely start of care.
This role will support care coordination activities furnished within the Providence hospital and develop opportunities for educational outreach that will enhance service awareness and access. Additional duties assigned may include collaboration with local Service Line leadership in essential meetings, reporting on tactical plans, and training/orientation.
The Care Transition Associate position is salaried and will not receive any bonus or compensation related to assisting with admissions to the JV home health agency or hospice. The Care Transition Associate may be assessed for success of achieving Value-Based Enterprise measures.
MAJOR CHALLENGES :
1. Demonstrates ability to cope with ambiguous and changing environment.
2. Demonstrates the ability to remain calm under pressure.
3. To establish and maintain positive working relationships with facility customers and JV hospice and home health agency staff.
4. To prioritize multiple tasks and work in a demanding, active setting.
5. Understanding purpose and function of Value-Based Enterprise agreement between Providence and JV for home health and hospice care coordination.
 

Position Specific Responsibilities

• • The job duties listed are essential functions of the position. However, other duties may be assigned, and may also be considered essential functions of the position.
  
  • The caregiver must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending upon the nature of the position.
  
  • Caregivers are expected to honor the Mission, Values, Vision and Promise and adhere to the Code of Conduct, policies and standards of their organization.
  
  • For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served.
  
  • Acts as a non-clinical liaison between inpatient and outpatient settings supporting post-acute service arrangements and coordination of care for patient discharge.
  
  • Assists the Clinical Liaisons and the inpatient acute care teams as part of the Value-Based Enterprise goals in arranging care for patients discharging with Home Health and Hospice care needs. Coordinates and arranges for admission of patients to home health and hospice service.
  
  • Obtains information to help Clinical Liaisons to assess patient appropriateness for hospice and home health services consistent with policies and procedures and admission criteria. Ensures services and equipment ordered are appropriate based on clinical criteria and patient diagnosis. Ensures required documentation is present in the patient chart. Obtains accurate charting and MD orders as needed to ensure appropriate insurance coverage.
  
  • Meets with Clinical Liaisons, hospital discharge planners, physician groups and other referral sources maintaining excellent customer relationships, ensuring satisfaction, providing updated materials, and informing of any updates on new or changes in services. Serves as a resource for inpatient care teams for patients discharging from the hospital to home health or hospice service lines.
  
  • Provides in-person education materials and consultation to patients and families regarding Home Health and Hospice. Coordinates delivery of equipment to the patient residence with Home Health Agency’s or Hospice’s HME and DME vendors as appropriate to avoid hospital discharge delays.
  
  • Communicates clearly to physician and provider offices verifying orders, following provider, pertinent medical and other information applicable to Home Health and Hospice clearly and concisely.
  
  • Provides administrative support for Clinical Liaison team.
  
  • Efficiently navigates EMR; enters patient data and appropriate documentation ensuring a high level of accuracy. Schedules starts of care for patients as needed.
  
  • Responsible for providing necessary documentation to internal and external agencies to ensure patients receive Home Health and/or Hospice care ordered at hospi